Distant Relative

You receive a call from a relative saying your 94 year old Aunt B. who lives in the west, has been rushed to the hospital and is in intensive care. Earlier in the day she had been having respiratory distress at her home and her son had transported her to the hospital for treatment. She is not able to talk and has been trying to pull out the I.V. in her arm. Aunt B. spent most of her career working with the elders in her community as a nursing assistant. She has been living alone in her own home for the last 50 years. She has one child a son. Her son has always lived close to her and visits her regularly. He is now 71 years old and recently diagnosed with a terminal disease. In the last 10 years Aunt B.’s health has declined due to a number of issues including a work related back injury (she had to early retire on disability), adult diabetes and lately heart issues. Within the last month the doctor had recommended her getting a pacemaker which Aunt B. has refused. Now you immediately think about the last telephone conversation (approximately two weeks ago) you had with Aunt B. She indicated that she was tired and did not want to go through any further treatment and stated, “I have had a full life and I am tired and want to die.” She also indicates she does not have living will nor a health care decisionmaking power of attorney. After talking with Aunt B. you call her son and he tells you he thinks his mother should agree to the pacemaker. Hearing Aunt B. has been rushed to hospital you ask yourself: What should be done? What can be done?

b.j.

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Kavan is a social media entrepreneur committed to growing the use of social networking towards promoting the equality, sustainability, health and well being of people of all ages. Combining careers as a national journalist and public relations expert, Kavan focuses on the power of user-generated content to communicate ideas and build movements.

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Reader Interactions

Comments

I concur with the group about reporting the conversation, seeing if Aunt B can communicate and working with hospital staff but want to stress the point about the son. Maybe he is feeling his own mortality in wanting to keep his mother alive as long as he is around. this would be the perfect time for him to make sure all his final plans are in place.

Aunt B was clear in asserting her desire to die. She has a right to refuse medical treatments that could extend her life and she has a right to choose dying. I would support Aunt B’s decision to return to her home to receive in-home care which may include hospice care. The absence of a living will or advance care directive would almost guarantee that she will not receive the pacemaker. So the hospital staff would have no choice but to discharge her.

Definitely share Aunt B’s comments and expressed withes with her son; this may make him change his mind. If not, it may be a good idea to at least let her physician know about the conversation so he/she can take that into consideration when having a discussion with her son. All of this is a moot point, however, if Aunt B has capacity to make a decison at this time.

The relative who spoke with Aunt B. 2 weeks has a moral obligation to convey the mother’s last conversation wishes to the son. However, from the information given, it appears that Aunt B. does not have diminished capacity and therefore can make insightful decisions regarding pacemaker insertion, Avance Directives, Health Care Agent (HCA), etc. through various communication techniques that are available. Social Services at the hospital can initiate paperwork for the AD’s if necessary and advocate for Aunt B’s request not to have any further treatment, i.e. pacemaker. I’m in agreement with Diane and Renee that this woman has already made an educated decision and it needs to be formalized in writing. If, for whatever reason, her wishes can not be formalized then it becomes paramount that the relative inform the son of his mother’s comments.

The son’s comment to his relative that he thinks his mother “should agree to the pacemaker” suggests that the son believes his mother is able to make the decision and that he is simply giving his opinion. As noted by others, the case does not provide enough information to determine if the mother has the capacity to decide. Also, since the relative initiated the call to the son, you could assume that the relative told the son about his mother’s intentions. If so, and without more information, I am not clear what more the relative needs to do. As noted by others, the relative could suggest to the son that they call the physician together, could offer to help with the advance directive process, and could even serve as the proxy, if asked. Sometimes doing nothing is the most difficult and correct thing to do. Tom

All have made very good points. I would also ask the son – given hi recent diagnosis – if he feels he is emotionally able to make the decision regarding his Mom’s treatment. Is he being objective? Of course, if Aunt B, can decise on her own – she can have this conversation with her son. In fact, she should suggest that they both document their wishes and assign a healthcc are and finacial POA.

I would speak with my cousin (Aunt B’s son) and inform him of the last conversation I had with Aunt B and also suggest that we speak with her doctor to see if she communicated any wishes to him since she was refusing a pacemaker. Once we have all the information we can gather and are sure Aunt B. can lend nothing to the conversation due to her condition, then I would be available to my cousin to make the proxy decision for my Aunt B.

I agree with the process others have outlined – first, determine whether Aunt B is able to make her own wishes known and whether the doctor has the ability, based on whatever way she can communicate (if at all), to assess her capacity to make her own decisions. If none of that is possible, then it seems that because she has not executed any advance directives, it would fall to her son to determine what happens next and the distant relative should certainly share what he or she knows about Aunt B’s wishes as she expressed them previously. It also sounds like Aunt B’s doctor who recommended the pacemaker has likely had previous conversations with her about her treatment options and may also be able to talk with the son as he strives to make the best decision for his mother, which would be one consistent with clear and convincing evidence of her own wishes.

If Aunt B. was able to clearly state her wishes during the phone call two weeks ago, you must make it clear to the son that you have information about her wishes, and he should make the decision not to go through with treatment, if Aunt B. cannot do so herself. If Aunt B. is still able, the son should have her fill out the directives and sign all the papers now, to avoid the problem of having to rely on your recounting the conversation and persuading people of her wishes.

Aunt B has made her wishes known. The relative has an obligation to share this information with Aunt B’s son and get the Doctor involved in helping him understand his mom’s wishes, especially in the context of her prognosis and the quality of her life. I am concerned that we constantly feel the need to question patient’s desires regarding their end of life decisions. We tend to always need a document to assure us that we are doing the right thing. In my opinion this becomes less about the patient and more about risk and legal consequences of our actions. (The main reason why health care is as expensive as it is today, and why Medicare is going broke)I would assume that Aunt B’s general condition is not significantly different today than it was two weeks ago. As Donna said, it sounds like both Aunt B and her son would need a lot of support. No offense to hospital staff, but I think once it gets to this level we tend to get caught up in too much bureaucracy and the patient’s wishes becomes secondary to the process. I would really count on her doctor “Primary care” who hopefully knows Aunt B very well, to help facilitate the discussion and support for end of life. A good Hospice organization could help both Aunt B and her son during this very difficult time of both of their lives.

Aunt B has made her wishes known. The relative has an obligation to share this information with Aunt B’s son and get the Doctor involved in helping him understand his mom’s wishes, especially in the context of her prognosis and the quality of her life. I am concerned that we constantly feel the need to question patient’s desires regarding their end of life decisions. We tend to always need a document to assure us that we are doing the right thing. In my opinion this becomes less about the patient and more about risk and legal consequences of our actions. (The main reason why health care is as expensive as it is today, and why Medicare is going broke)I would assume that Aunt B’s general condition is not significantly different today than it as two weeks ago. As Donna said, it sounds like both Aunt B and her son would need a lot of support. No offense to hospital staff, but I think once it gets to this level we tend to get caught up in too much bureaucracy and the patient’s wishes becomes secondary to the process. I would really count on her doctor “Primary care” who hopefully knows Aunt B very well, to help facilitate the discussion and support for end of life. A good Hospice organization could help both Aunt B and her son during this very difficult time of both of their lives.

I would share the conversation with the son. And as Sarah said, if Aunt B. is able to communicate her wishes they should be followed. With both the son and the mother facing terminal illnesses, this family will need a lot of support. The family, social worker, clergy, etc. should be involved in helping them make these decisions.

Depending on my relationship with Aunt B’s son, I would share the conversation I had with his mother. He seems close to his mother, so he should have this information before making a health care decision for her.

Since he has recently been diagnosed with a terminal illness, it might be a good opportunity to talk about his preferences for his own treatment as well.

Sarah brings a good point, can she now communicate her wishes? If so then dilemma resolved. If not, then the relative must communicate the last convresation to the son who is line to make decsions without any further clear evidence. Maybe the son who has been close with his mom knows more than the distant relative and Aunt B. just made those comments in a moment of sadness. Hopefully the son knows more and keeps his emotions and the internal conflict he may be feeling out of making his decison for his mom. Regardless the relative needs to talk to the son and make her aunt’s comments clear to him and seek the help of the hospital.

It must first be established if Aunt B can communicate at this time or not. We know she can not talk but is she able to communicate through writing or gestures (i.e. nodding yes/no)? The attempt to remove her IV could be due to discomfort and not necessarily a will to die. If Aunt B cannot communicate her wishes at this time, your previous conversation with her should be conveyed to the person(s) making the medical decisions.

I agree with Diane. It is clear that Aunt B knows her options and has decided that she does not want to pursue treatment. If I were the distant relative I would try to persuade Aunt B to complete an advanced directive so her wishes will be adhered to. If not then as Diane indicated social services at the hospital shoudl be contacted to intervene.

Aunt B needs a healthcare power of attorney and an advanced directive in place. She has made the choice not to have treatment. She has made and educated and informed decision. It needs to be put in writing. Aunt B needs to make her wishes known to her family, her doctor and her friends.

Social service at the hospital should be contacted and asked to intervene and get this process started. If aunt B wants to continue not to seek treatment, then hospice should be given consideration. A person can choose to not be treated and not be hospitalized if they choose.